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    Estimate Format

    Uploaded by

    Mangesh Virkar
    This document provides an estimate of medical fees for a procedure, noting that it is an estimate only and additional costs may be incurred. It lists the patient's details and procedure details, and indicates whether the patient is likely to have a gap payment to make based on their health fund benefits. The patient must sign to acknowledge they understand the estimated costs are not final and can vary.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Estimate Format

    Uploaded by

    Mangesh Virkar
    66 views1 page
    This document provides an estimate of medical fees for a procedure, noting that it is an estimate only and additional costs may be incurred. It lists the patient's details and procedure details, and indicates whether the patient is likely to have a gap payment to make based on their health fund benefits. The patient must sign to acknowledge they understand the estimated costs are not final and can vary.

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    Estimate

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    estimate format

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    This document provides an estimate of medical fees for a procedure, noting that it is an estimate only and additional costs may be incurred. It lists the patient's details and procedure details, and indicates whether the patient is likely to have a gap payment to make based on their health fund benefits. The patient must sign to acknowledge they understand the estimated costs are not final and can vary.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    66 views1 page

    Estimate Format

    Uploaded by

    Mangesh Virkar
    This document provides an estimate of medical fees for a procedure, noting that it is an estimate only and additional costs may be incurred. It lists the patient's details and procedure details, and indicates whether the patient is likely to have a gap payment to make based on their health fund benefits. The patient must sign to acknowledge they understand the estimated costs are not final and can vary.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    LOGO ESTIMATE OF MEDICAL FEES

    Estimate of Medical Fees


    As a service to our patients, we provide the following estimate of the likely medical costs you will be required to pay for your procedure.
    You should discuss these costs with the doctor or doctor’s staff preferably before your procedure.
    Please note that it is an estimate only. Unless specified, the estimate refers only to the fees charged by this practice. It does not cover services
    provided by other doctors, including radiologists, nuclear physicians and pathologists, nor other costs associated with your episode. eg.
    accommodation facility, pharmacy and physiotherapy.
    In the event of unforeseen circumstances, it may be necessary to arrange additional medical services, resulting in further charges to you.

    Patient’s Details
    Patient’s Name

    Patient’s Address State Postcode

    Health Fund Name Hospital Date of Admission


    / /

    Procedure Details
    REMARK Patient Gap
    Total benefits (Medicare/
    Payment
    Item number(s)/Description of Service(s) Fee Health Fund Benefit) –
    (See Note 1)(optional)

    You are likely to have a gap to pay Yes No If yes, please refer to your Health Fund for additional information not provided above.
    Pathology and Radiology services are likely to be required during your episode of care.

    Any financial interests in products or services recommended or given to the patient have been disclosed to the patient Yes N/A
    NOTES:
    1. Total Benefit This includes the medical rebates payable by Medicare and your Health Fund which together provide a
    contribution to the cost of the medical service. For a no gap product it will equate to the practitioner’s fee. For
    further information patients should approach their Fund.
    2. Patient Gap Payment Where the Medicare and Health Insurance Fund rebates do not cover the entire cost of the medical service, the
    ‘Patient Gap Payment’ represents the part of the cost of the medical service which you, the patient, will pay
    yourself.

    Patient/Guardian to complete

    The above estimated costs have been explained to my satisfaction. I understand that the above costs are an estimate and subject to variation.
    It is not a consent to, nor a request for, a procedure.

    Patient/Guardian’s Signature Date

    / /

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